Cardenas & Associates Physical Therapy

2016
PATIENT INFORMATION ACKNOWLEDGMENT FORM

I have read and fully understand Cardenas & Associates Physical Therapy ‘s Notice of Information Practices. I understand that Cardenas & Associates Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that Cardenas & Associates Physical Therapy will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions.

I hereby consent to the use and disclosure of my personal health information for purposes as noted in Cardenas & Associates Physical Therapy ‘s Notice of Information practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

Patient Name

Patient/ Guardian Signature

Date

I also authorize Cardenas & Associates Physical Therapy to use my protected health information for targeted marketing, fund raising, and/or solicitation of participation in research studies. I understand I have the right to copy or inspect any information used for these purposes. I also understand this authorization does not affect my consent to use my protected health information for treatment, billing, or operations related to treatment and billing.

Patient Name

Patient/ Guardian Signature

Date

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